GENERAL Have you served in the U.S. Armed Forces? Branch from / to / Rank at Discharge----- Date of Discharge or Release Have you ever been bonded? Name of Bonding Company In order for you to drive a company or leased vehicle for Mid Continent Trucking Co., you must have a valid Class "A" commercial motor vehicle license from your state of residence. Do you presently have such a license? Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Have you ever had any license, permit, or privilege suspended or revoked? If the answer to either of the above is yes, then attach a statement giving details. Info. Will be used only if job related. LIST ALL DRIVER'S LICENSES YOU HA VE HELD IN THE PAST THREE (3) YEARS STATE LICENSE NO. TYPE EXPIRATION DATE ENDORSEMENTS DRIVER'S LICENSE EDUCATION High School Grade Completed Other Schools College Last school attended: -------------------------------- NAME CITY List Degree(s), training and safe driving awards you hold and from whom: EXPERIENCE AND QUALIFICATIONS DRIVING POSITIONS Do you have a current DOT Medical Card? Do you have full knowledge of DOT Safety Requirements? Have you ever been disqualified from driving for any of the following? 1. Driving a commercial motor vehicle with a blood alcohol concentration of 0.04 or more? Yes ( ) No ( ) 2. Driving under the influence of alcohol, as defined by State law? Yes ( ) No ( ) 3. Refusing to submit to an alcohol test at the direction of Federal, State or local officials? Yes ( ) No ( ) 4. Driving a motor vehicle with a gross vehicle weight rating of I 0,00 I pounds or more while under the influence of an illegal drug (including the improper use of prescription drugs)? Yes ( ) No ( ) 5. Transporting, possessing or using illegal drugs (including the improper use of prescription drugs) while on duty? Yes ( ) No ( ) 6. Leaving the scene of an accident while operating a commercial motor vehicle? Yes ( ) No ( ) 7. Committing a felony involving the use of a motor vehicle with a gross vehicle rating of 10,001 pounds or more? Yes ( ) No ( ) Have you tested positive in a DOT required drug or alcohol test in the past two years, or refused a test for an employer who did not hire you? Yes ( ) No ( ) If yes, provide details on a separate sheet of paper.
HireRight Customer: Company Name: Company Contact Name: TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization Send to Fax# (800) 257-8069 Fax #: ( ) - HireRight Account Code: PART I DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adul terated and/ or s ubstituted t ests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 S ubpart B); (v) information obtained from previous employers of a drug and al cohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any c ompany l isted bel ow f urnishes HireRight with information concerning items (i) t hrough (vi) above, I al so aut horize such company t o f urnish t he f ollowing i nformation t o HireRight, i f appl icable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years. List a ll DOT-regulated employers you have applied w ith and/ or w orked for in a safety-sensitive f unction during t he previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature. Previous DOT-Regulated Employer City State Phone Number ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (i ii) pr ior t o s igning I was gi ven an opportunity t o as k ques tions and to have those questions answered to my satisfaction; ( iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful pur pose; ( v) I understand I may review this document with legal counsel prior to signing; and (vi) f acsimile or photographic copies of this authorization are as valid as an original. Print Applicant Name: Social Security #: Applicant Signature: Date: DOT Drug/Alcohol Disclosure/Authorization Trucking Industry Employment Purpose 4/10
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALLACCOUNTHOLDERS IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). In connection with your application for employment with Mid Continent Trucking Co. When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FM CSA in a decision to not hire you or to make any other adverse emp1oyment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a \Vlitten summary of your rights under the Fair Credit Repmiing Act before taking any final adverse action. If any final adverse action is taken against you based upon your d1iving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FM CSA; the name, address, and the toll free telephone number offmcsa; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the repori, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FM CSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.frncsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FM CSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a comi oflaw will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Mid Continent Trucking Co. ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.frncsa.dot.gov. If I challenge crash or inspection information reported by a State, FM CSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it \Vl.ll include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FM CSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear 1